Cognitive impairment (Cl) is a major health problem complicating the care of increasing numbers of hospitalized older adults. Dementia and delirium, the most common causes of Cl among these elders, are associated with higher mortality rates, increased morbidity and higher health care costs. A growing body of science suggests that these patients and their caregivers are particularly vulnerable to systems of care that either do not recognize or ignore their needs. The consequences are devastating for these patients and add tremendous burden to hospital staffs coping with a severe shortage of nurses and caregivers facing the difficult transition from hospital to home. Unfortunately, little evidence exists to guide optimal care of this patient group. Available research findings suggest that hospitalized cognitively impaired elders may benefit from interventions aimed at improving care management of both Cl and comorbid conditions but the exact nature and intensity of intervention needed to efficiently and effectively enhance patient, caregiver and cost outcomes are not known. The proposed study addresses these important gaps in knowledge, building on our team's extensive body of research testing care management interventions with high risk, cognitively intact elders. Guided by Roy's Adaptation Model, we initially propose to compare across three hospital sites the effects of three interventions of different intensities and varying nurse staffing and skill set requirements, each designed to promote positive adaptation to an acute illness by cognitively impaired hospitalized elders and their caregivers: augmented standard care (ASC); resource nurse care (RNC) and advanced practice nurse care (APNC).The relative effectiveness of the interventions will be estimated statistically, accounting for patient characteristics found to most increase the likelihood of being admitted to one institution compared to another. By controlling for these likelihoods, or propensities, the potential effect of selection bias on treatment efficacy comparisons is minimized. Moreover, we propose to 'cross-over' to APNC in the sites originally selected to provide ASC and RNC in order to confirm findings from the initial parallel groups' comparisons while continuing with APNC in the third site to assess the contribution of time effects. Models will account for pre-existing dementia, depression, severity of illness, race, age, and gender. Relative efficacy and cost-effectiveness for both the parallel groups and site cross-over phases will be determined based on the following primary outcomes: change in functional status, time to first rehospitalization or death; total number of rehospitalized days; caregiver burden and health care costs. Data analysis will include analyses of covariance, mixed model analyses for longitudinal outcomes, Kaplan-Meier and Cox regression for time to event outcomes, logistic regression for dichotomous outcomes, and methods for cost estimation in the presence of censored follow-up including bootstrap estimation of confidence intervals. The relationships between processes of care and outcomes will be assessed in exploratory analyses. Findings have the potential to inform improved care management of these patients and their caregivers, an Institute of Medicine priority for national action.